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On February 10, 2015,
India’s first National Deworming
Day, 89 million
children received treatment
at schools and preschools
for parasitic worms. Our small organization,
Evidence Action, worked with
India’s national and state governments and
a host of other stakeholders to accomplish
this task—the largest one-day deworming
program to date.

How did we achieve that kind of
reach with just 50 full-time employees
and a handful of short-term workers in
India? Our success is based on a three-prong
strategy: a sustainable program
structure, skilled advocacy, and targeted
technical assistance. A bit of background
might help explain how we came to do
this work in India.

As our name implies, Evidence Action’s
mission is to scale up rigorously evaluated
programs, filling the gap between knowing
what works and achieving large-scale
impact. When Evidence Action launched
in 2013, we took over the management of
the Deworm the World Initiative, which
works with governments to develop and
implement national school-based deworming
programs. Deworm the World grew out
of research in Kenya and was incubated
by Innovations for Poverty Action, a nonprofit
research network that designs and
evaluates solutions to global poverty. We
continue that work in Kenya and recently
added Ethiopia, but the program in India
is our largest.

Parasitic worms are endemic in India,
where an estimated 241 million children
are at risk. The highest rates of infection
tend to be among children between ages
5 and 15. If untreated, worm infections interfere
with nutrient uptake and can result
in anemia, malnourishment, and impaired
mental and physical development. They
pose a serious threat to children’s health,
education, productivity, and even lifelong
earning potential. Yet research shows that
deworming is safe, easy, and effective.

The Abdul Latif Jameel Poverty
Action Lab considers school-based deworming
a “best buy” in global health
because it reduces school absenteeism, improves
cognition and nutrition, and boosts
future earnings—all for about 10 cents per
child annually. Although mass treatment
has some detractors, most experts and organizations,
including the World Health Organization (WHO), endorse it over
screening, which costs four to ten times
as much as the treatment itself.

Capitalize on Existing Infrastructure

Deworming through schools—as opposed to health centers or
home-based visits—reaches
a large number of children at risk while
minimizing costs. Teachers dispense the
chewable pills once or twice a year, depending
on how prevalent worms are in
the area. Treatment decisions are based
on the best available current guidelines
by the WHO. School-based deworming
programs aim to treat at least 75 percent
of children at risk. And experience in
other countries shows that school-based
programs work. The annual national deworming
program in Kenya, for example,
reduced the prevalence of parasitic worm
infections among schoolchildren from 33
percent to 18 percent from 2013 to 2014
alone. Prevalence rates—the percentage
of children found with worms when
tested—right after the 2014 deworming
round fell to as low as 6 percent.

Identify Champion Government Officials

Succeeding in India required skilled
advocacy. Parasites are a disease of
poverty, and those most affected
lack a strong political voice. In a country
of about 1.3 billion people with 29 states
and seven union territories—each with its
own government—establishing a national
deworming program is a logistical and
political achievement of some magnitude.
India faces many public health problems
that need attention, such as malnutrition,
anemia, and widespread open defecation.
As government agencies and NGOs prioritize
public health issues, deworming easily
gets lost among competing priorities.

Although deworming programs are
not new to India, large-scale school-based
programs are. We are one of the few groups
giving concentrated attention to the issue.
To begin, we focused on reaching decision makers, first in India’s national
government, which sets policy, develops
program guidance, and provides funding
to state governments. We worked closely
with the Ministry of Health and Family
Welfare and met frequently with officials
there to discuss the problem and then
worked with them to create a plan for a
scalable program.

To advocate effectively, we described
the gains made already in a number of
Indian states and other countries. We also
shared information on the prevalence of
soil-transmitted parasites in different regions
of India. Officials asked for detailed
additional information, including effective
methods for rolling out large-scale
deworming programs.

We understand that government agencies are often understaffed and have to deal with any number of priorities. So we try to make it easy to support a deworming program.

Securing support at a national level
was helped by the fact that we had already
been working in several states with the local
Health, Education, and Women and Child
Development departments. We had learned
there to tailor our communications and emphasize
our work’s connection to priority
issues. For example, when we talked with
education officials we focused on cognitive
and educational benefits. When we spoke
with staff in the Department of Health, we
focused on the health impacts of deworming.

We understand that government agencies
are often understaffed and have to deal
with any number of priorities. So we try
to make it easy to support a deworming
program. Before speaking with state officials,
for example, we look at available
data on worm loads and proxy indicators
such as open defecation, anemia, and
malnutrition rates, in addition to budgets
and policies. If the state has a vitamin A
supplement program for children, but not
a deworming program, we advocate robust
deworming as well, because evidence
shows that vitamin supplementation is not
as effective if a child has worms. This kind
of background research helps to make an
effective case for mass deworming.

Provide Targeted Technical Assistance

We also offer two levels of
technical assistance to state
ministries of health and education
as needed: light and comprehensive.
Light technical assistance works best for
a state that already has the infrastructure
for a robust deworming program and the
resources to train teachers and pre-school
workers. These states might need help in
specific areas, such as mobilizing communities,
and look to us to design a public
awareness campaign.

Our comprehensive package of technical
assistance, which runs from three to
five years, assists governments in building
a program from the ground up. Teachers
and health care workers, for example,
must be trained to administer medicine
and educate children and communities
about sanitation, hygiene, and preventing
worm infections. In addition, we conduct
surveys to determine worm prevalence,
develop detailed operational plans, assist
with procurement of drugs through donation
programs, and monitor the quality of
the program as it is implemented. We essentially
provide all of the elements needed
to create a good program and localize it for
the community. And we do all the organizational
legwork, such as getting the critical
people together and helping them get the
trained staff needed to run the program.

We currently work in six Indian states,
providing comprehensive technical assistance
to five. Engaging to this degree of
depth requires our staff to be diligent. In
addition, we use short-term workers for
specific tasks, such as calling schools and
collecting monitoring data during the deworming
program so that we can assess
how well it is implemented. Regardless of
the level of support we provide, Evidence
Action creates a customized plan that delivers
what governments need. For example,
a state government may ask us to assist
with determining the extent of program
coverage and the reliability of reporting
on implementation.

In every case, a central component of
our technical assistance is gathering and
sharing evidence that governments can
use to build best practices. For example, we
are building a database that shares detailed
costing for each state we work with. Those
models help states assess what it costs to
run a mass deworming program. In addition,
we monitor the quality of deworming
programs, enabling our partners to make
better management decisions and create
more effective programs.

In India, some states have been deworming
school children for several years,
but because they may not measure results,
they may not know how effective their
programs are. We help them measure the
prevalence of worms before deworming,
as well as their reach and coverage. In one
instance, a large state treated 21 million
children twice a year. This year, we did a
prevalence survey and determined that
it needed to do only one high-coverage
round of deworming per year, saving
resources that the government could use
for other priorities.

Delivering deworming medicine to 89
million children on India’s first National
Deworming Day represents a significant
victory in the global fight against soiltransmitted
diseases and other parasitic
worms. The government of India has demonstrated
a strong commitment towards
tackling the public health threat of worms.
We at Evidence Action are focused on continued
advocacy and technical assistance
for school-based mass deworming in India
and elsewhere. Perhaps our strategy can
help other organizations have the same
sort of outsized impact delivering proven
interventions.

Priya Jha is India director of Evidence Action. She was previously country representative in the India Office for the Institute for Reproductive Health at Georgetown University.